Part 18, page 115
Document date 24 November 1971
FBI 164-81, Vault Part 18 p. 115 (DB Cooper-5448), Form, dated 24 Nov 1971 — cooper.theunsolved.net/parts/Cooper-Part-18/pages/115
Transcript
The scan is the source; the transcript is machine-generated from it.
Policy Number A 059982
PERSONAL ACCIDENT WITH DOUBLE PROTECTION ON SCHEDULED AIRLINES Amount of Insurance: $20,000 Capital Sum (Scheduled Air) $40,000 Principal Sum (Other Acc.) PREMIUM $ 1.00
BAGGAGE AND PERSONAL EFFECTS $ none Amount of Insurance PREMIUM $ none
COMBINED PREMIUM $______ Term of Coverage: 5 Days Countersigned by ___________
----- Please Print ----- [redacted] ...upation Address of Insured
City [guess: Monmouth] [guess: ate] Ore. ZIP Code Name of Beneficiary Address of Beneficiary Same City ________ State ________ ZIP Code
Effective at: Hour 1:00 [X] p.m. Date 11-24-71 Month Day Year Place PDX
Personal Signature of Insured [blank]
AGENT COPY
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Policy Number A 33268
PERSONAL ACCIDENT AND SICKNESS $ 10,000 Amount of Insurance Insured Only Premium $ 3.20 Dependent Premium $ 1.60 TOTAL PREMIUM $ 4.80
BAGGAGE AND PERSONAL EFFECTS $ none Amount of Insurance PREMIUM $ none
COMBINED PREMIUM $______ Term of Coverage: 5 Days [guess: Countersigned by] ___________ [guess: Licensed Resident Agent] ___________
----- Please Print ----- [redacted] Address of Insured
City Vancouver State Wash ZIP Code Name of Beneficiary Address of Beneficiary City Vancouver State Wash ZIP Code
Effective at: Hour 11:10 [X] a.m. Date 11-24-71 Month Day Year Place PDX
Personal Signature of Insured [blank]
AGENT COPY
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DB Cooper-5448
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b6 b7C